Enterococcal Septicemia Research Articles

Fatal septicemia by multidrug-resistant Enterococcus faecium in a case of exomphalos minor

Exomphalos minor is one among uncommon disorders of the umbilical region. Here, we report a fatal case of exomphalos minor with enterococcal septicemia. A male baby, born with exomphalos minor, developed clinical features of septicemia on the fourth postnatal day. Blood samples were collected by venepuncture from two sites for culture. Enterococcus faecium was isolated from both the blood samples. The swabs collected from the site of exomphalos also yielded growth of Enterococcus faecium, confirming the source of infection. The antibiogram with Minimum Inhibitory Concentrations (MIC) for various antibiotics was done for isolates from all three sites, which was similar. The isolate was resistant to multiple antibiotics with high level aminoglycoside resistance. The baby was treated with antibiotics and other supportive measures. However, the baby succumbed to the septicemia. As per our knowledge, this is the first reported case of fatal septicemia by multidrug-resistant Enterococcus faecium in a case of exomphalos minor.

Clinico-epidemiological profile and high-level aminoglycoside resistance in enterococcal septicemia from a tertiary care hospital in east Delhi

Background:Emergence of high-level aminoglycoside and glycopeptide resistance has significantly contributed to the mortality, particularly in serious enterococcal infections.Objectives:This study was aimed to determine the prevalence of high-level gentamicin resistance (HLGR), high-level streptomycin resistance (HLSR) and vancomycin resistance in enterococcal isolates recovered from patients with bacteremia.Materials and Methods:A total of 110 blood culture isolates of enterococci were recovered from septicemic patients. Routine antibiotic susceptibility testing was performed and screening for ampilcillin, high-level aminoglycoside resistance (HLAR) and high-level vancomycin resistance was done by agar screen method.Results:Out of 110 isolates, Enterococcus faecium accounted for 53% of these isolates, followed by Enterococcus fecalis (33%), Enterococcus casseliflavus (8%), Enterococcus raffinosus (4%) and Enterococcus dispar (2%). Resistance to ampicillin, HLGR, HLSR and HLAR was detected in 58%, 62%, 58% and 54% of the isolates, respectively. No isolate was resistant to vancomycin.Conclusion:This study illustrates the high prevalence of HLAR in enterococci from patients with septicemia in our region, which emphasizes the need to predict synergy between beta-lactams and aminoglycosides for management of enterococcal infections.

Infective Endocarditis—An Uncommon Cause of Unexpected Death

ABSTRACTInfective endocarditis can rarely present as a sudden or unexpected death occurring outside of hospital. Two such cases were studied and the diagnosis was determined only after autopsy examination. A 36-year-old male intravenous drug abuser had staphylococcal and enterococcal septicemia and endocarditis of the mitral valve. He died in jail five days after presenting with nausea and vomiting. The other case was an asymptomatic 30-year-old male with a bicuspid aortic valve and a coarctation of the aorta who developed Streptococcus viridans endocarditis and was found dead at home one hour after last being seen alive. Both had left ventricular failure from valve perforation and subsequent valve incompetence. The drug abuser had evidence of disseminated infection. Infective endocarditis was confirmed by appropriate histopathological examination and microbiological culture.

Antimicrobial activity of MDL 63,246, a new semisynthetic glycopeptide antibiotic.

MDL 63,246 is a semisynthetic derivative of the naturally occurring glycopeptide antibiotic MDL 62,476 (A40926). It was more active in vitro against Staphylococcus aureus and coagulase-negative staphylococci than MDL 62,476, teicoplanin, and vancomycin and was more active than mideplanin (MDL 62,873) against some isolates. MDL 63,246 had excellent activity against streptococci and teicoplanin-susceptible enterococci, and it also had in vitro activity against some VanA enterococcal isolates. It was more active than teicoplanin and vancomycin against acute staphylococcal, streptococcal, and enterococcal septicemia in immunocompetent and neutropenic mice. It was highly efficacious in reducing the bacterial load in the hearts of rats in staphylococcal endocarditis experiments and the bacterial load of Staphylococcus epidermis in a high infection model in neutropenic mice. The excellent in vivo activity of MDL 63,246 appears to correlate both with its in vitro antibacterial activity and with its long half-life in rodents.

Clinical and molecular epidemiology of enterococcal bacteremia in a pediatric teaching hospital

An apparent increase in the incidence of enterococcal bacteremias from 7 to 48/1000 bacteremias during 1986 to 1991 (p < 0.01) prompted this descriptive clinical and molecular epidemiologic study of 83 episodes occurring in 80 children between 1986 and 1992. Most community-acquired cases were in infants, in comparison with nosocomial episodes (24/26 and 34/57; p < 0.01); many of them were neonates (10/26 and 6/57; p < 0.01). Nosocomial cases were associated with underlying conditions including major surgery 56%, immunosuppression 49%, organ and tissue transplants 30%, and cardiac 32%, pulmonary 25%, renal 21%, and hepatic 21% disorders. Nosocomial episodes developed after a median of 32 days. There were 58 primary and 25 secondary bacteremias. Thirty-two episodes were polymicrobial and 44 organisms were involved. Twenty-six percent of the patients died. In 15%, death was preceded by septic shock, disseminated intravascular coagulation, and polymicrobial bacteremia (p < 0.01). Of 75 isolates, 82% were Enterococcus faecalis and 14% were Enterococcus faecium. Fourteen E. faecalis strains produced hemolysin; none produced beta-lactamase. Three had high-level resistance to gentamicin and 13 to streptomycin; two E. faecium and none of the E. faecalis strains were vancomycin resistant at a low level (p < 0.01) and one was ampicillin resistant. Pulsed-field gel electrophoresis of whole-cell DNA digested with restriction enzymes Sma I and Eag I showed five isolates with a homogeneous pattern, two with another homogeneous pattern, and 68 with distinct heterogeneous patterns. The increase in enterococcal bacteremias was not due to a clonal strain dissemination but to an increase in cases of heterogeneous enterococcal strains. We conclude that enterococcal septicemia is now an important cause of serious morbidity and death in critically ill children.

Enterococcal septicemia in patients with hematological malignancies.

Thirty-six cases of enterococcal septicemia in patients with hematological malignancies were reviewed retrospectively and categorized according to their clinical significance using strict previously described definitions. Overall, most of the infected patients were males (77%), had acute leukemia (64%), had recently received cytotoxic drug therapy (86%), were granulocytopenic at the onset of septicemia (77%), and acquired the infection during hospitalization (77%). The source of septicemia was unknown in 18 (50%) patients, intestinal in 15 (42%) and intravascular in three (8%). Mortality was 19% among 21 inpatients who had clinically significant septicemia and 30% among patients with septicemia of uncertain clinical significance. The fatal outcome could be definitively attributed to enterococcal septicemia in only one of the nine inpatients who died. Clinically significant septicemia appeared somewhat more frequently to be polymicrobial (p = 0.06), whereas septicemia of unknown significance presented more frequently as breakthrough septicemia (p = 0.013). Unless associated with intravascular infection, enterococcal septicemia in patients with hematological malignancies seems to represent a marker of cytotoxic drug damage of the intestinal mucosa rather than a truly invasive infection.

Isolation rates and pathogenicity of enterococci in obstetric and gynecological operations.

Isolation of enterococci in patients undergoing obstetric and gynecological operations was studied as well as reviewing the postoperative infection due to this organism during the period from 1985 to 1990. 1) In 126 cases undergoing abdominal total hysterectomy, vaginal specimens were obtained before and after (3rd day) the operation. The isolation rates increased after the operation (before 16.7%, after 35.7%). They increased not only in the group using PIPC, CEZ, CEPR, CMZ, and LMOX by drip infusion but also in the group without prophylactic use of antibiotics. On the other hand in the group using CP vaginal suppositories, the isolation rate decreased. However no statistical proof was obtained as to antibiotics especially in regard to cephem drugs as the reason for the increase. 2) Enterococci were isolated from the surgical field during abdominal total hysterectomy in only 2.0% (n = 88). 3) Isolation rates of enterococci inside the transvaginal drain following radical hysterectomy (n = 30) reached 86.7%. 4) E. faecalis was isolated in 20.0% of the cases with wound infection (n = 25). However isolated Enterococcus strains were not regarded to be the causative organism. 5) There was one case of postoperative enterococcal septicemia in treating stage Ib adenocarcinoma of the uterine cervix.

名古屋大学病院における腸球菌敗血症の臨床的検討と臨床分離株の薬剤感受性

Enterococci are important causative organisms of nosocomial infections as well as methicillin resistant Staphylococcus aureus and Pseudomonas aeruginosa. Enterococcal bacteremia has been increased in Nagoya University Hospital from April 1983 to March 1990. We analyzed the clinical backgrounds, portal of entry and mortality for the patients with Enterococcal septicemia. Thirty-four cases with enterococcal septicemia (24 Enterococcus faecalis, 10 Enterococcus faecium) were subjected in this study. Twenty-seven cases were monomicrobial septicemia and 7 cases were polymicrobial septicemia. As to the portal of entry, intra-abdominal infections in 21 cases, urinary tract infections in 4 cases, respiratory tract infections or chest tubes in 2 cases, decbitus infection in 1 case, intravascular catheter in 1 case, and unknown sources in 5 cases. Total mortality of the septicemia was 44.1%. E. faecium and Enterococcus avium were much more resistant to antimicrobial agents than E. faecalis. Enterococci with high-level resistance to gentamicin (minimal inhibitory concentration, greater than 2000 micrograms/ml) accounted for 35% of the 26 clinical isolates of enterococci.

Enterococcal Sepsis in Neonates: Features by Age at Onset and Occurrence of Focal Infection

Fifty-six neonates with enterococcal septicemia in a single hospital from 1977 through 1986 were studied. The incidence was low and constant until 1983, when an increase, attributable to infections in infants older than 7 days of age (late-onset), was noted. These infants were more premature (mean gestational age 29.5 vs 36.9 weeks) and had lower birth weights (mean 1250 vs 2700 g) than those with early-onset enterococcal sepsis, and in most the infections were characterized by a nosocomial origin. Infants with early-onset infection had a mild illness with respiratory distress typical of other etiologic agents or diarrhea without focal infection. By contrast, late-onset enterococcal sepsis was heralded by severe apnea, bradycardia, circulatory collapse, and increased ventilatory requirements. Focal infections, including scalp abscess or catheter-related infection (23% each), meningitis or pneumonia (15% each), were common. Rapid clinical improvement and clearance of bacteremia resulted from therapy with an aminoglycoside and either ampicillin or vancomycin, but only if abscesses were drained and intravascular catheters were removed. Mortality rates for early-onset, late-onset, and necrotizing enterocolitis-associated infection were 6, 8, and 17%, respectively. Enterococcus is a frequent cause of late-onset septicemia in premature neonates, and empiric therapy should include appropriate antimicrobial agents.

Intravenous ciprofloxacin and ceftazidime in serious infections: A prospective, controlled clinical trial with third-party blinding

Oral ciprofloxacin has been shown to be effective in the treatment of infections due to gram-positive cocci and gram-negative rods. The efficacy and safety of intravenous ciprofloxacin was compared with that of intravenous ceftazidime in the treatment of 59 patients with well-documented serious infections in a prospective, controlled, randomized study with a third-party blinding. Thirty-three patients were treated with intravenous ciprofloxacin (200 mg every 12 hours, plus a daily extra placebo dose); 26 patients were treated with ceftazidime (1 g every eigth hours). The severity of the infections, underlying diseases, and demographic features were comparable in both groups, although, there were more men in the ciprofloxacin group. For ciprofloxacin/ceftazidime treatments, respectively, the evaluated infections were: pyelonephritis (16 patients/nine patients), pneumonia (three/five), soft-tissue infections (four/zero), spontaneous peritonitis (five/two), primary bacteria (three/eight), and other (two/two). Isolated pathogens included: Escherichia coli (22/12), Klebsiella sp. (five/four), Pseudomonas aeruginosa (two/three), Haemophilus influenzae (one/one), Proteus mirabilis (two/zero), Proteus vulgaris (one/zero), Salmonella sp. (zero/two), Plesiomonas shigelloides (one/zero), and others (one/four). The clinical responses were cure or improvement in 31 ciprofloxacin cases/21 ceftazidime cases; failure, zero/four; and indeterminate, two/one. The bacteriologic responses were eradication in 28 ciprofloxacin cases/22 ceftazidime cases; persistence, one/three; and indeterminate, four/one. Mild intolerance occurred in three ciprofloxacin cases and two ceftazidime cases. A mild increase in serum hepatic enzymes was observed in two patients in each group. Superinfections occurred in five patients: enterococcal septicemia (zero/two) and urinary tract infections (one/two). The results presented suggested that intravenous ciprofloxacin is an effective and safe antimicrobial agent for the treatment of serious infections, with an efficacy comparable with that of ceftazidime, a broad-spectrum cephalosporin. An additional advantage seems to be a lower rate of superinfections.

Role of enterococcus in intraabdominal sepsis

Although enterococcus is well recognized as a pathogen in endocarditis, urinary tract infections, and biliary sepsis, its role in other forms of intraabdominal sepsis remains controversial. Antibiotics that lack activity against enterococcus can often be employed successfully in intraabdominal infections, even when enterococci are present as part of the polymicrobial flora. Furthermore, the enterococcus rarely emerges as a blood borne pathogen in such a setting. Breakthrough enterococcal septicemia may occur, however, in the immunodepressed host, particularly in the face of broad-spectrum antibiotic therapy not specific for enterococcus. Like infections with other opportunistic pathogens, enterococcal sepsis under these circumstances carries a high mortality. Specific antienterococcal drug therapy may be indicated as an adjunct to surgical management in selected patients with intraabdominal sepsis.

A trial in infection prevention in autologous bone marrow transplantation by selective intestinal decontamination

In an attempt to prevent infections complicating bone marrow transplantation, selective intestinal decontamination was carried out in 3 patients. The antibiotic regimen consisted of oral gentamicin (960 mg/day) and amphotericin B (800-1600 mg/day) (GA).Aerobic gram-negative bacilli initially cultured from the feces were completely suppressed within one week after initiation of antibiotic prophylaxis. On the other hand, the number of anaerobic bacteria remained unchanged during GA administration. In 2 patients GA administration extended over a period of 8 weeks. In one patient aerobic gram-negative bacilli were not isolated during antibiotic prophylaxis. In the other patient, gentamicin-resistant Klebsiella pneumoniae appeared when fecal anaerobic flora was completely suppressed by intravenous cefmetazole administration. Candida persisted in 2 patients despite the prophylaxis. The suppression pattern of the throat flora after initiation of the oral antibiotics was similar to that observed in the stool. Diarrhea, weight loss and hypocholesterolemia were noted during the prophylaxis. Nausea and vomiting were often associated with the radio-chemotherapy. During antibiotic prophylaxis enterococcal septicemia developed in one patient. This organism persisted in the patient's own stool during the antibiotic prophylaxis.Therefore, GA is thought to produce satisfactory suppression of intestinal aerobic gram-negative bacilli and deserve further study.

'Breakthrough' enterococcal septicemia in surgical patients. 19 cases and a review of the literature.

We studied 19 surgical patients with 24 postoperative episodes of enterococcal septicemia not arising from the biliary or urinary tracts or from infected heart valves. Fifteen episodes occurred despite the administration of broad-spectrum antibiotics; in only one patient were these drugs effective against enterococcus. There were 14 episodes of enterococcemia in 11 patients following which the patient survived for at least one week. Thirteen (93%) of those episodes were treated with either ampicillin or drainage, or both. Five of the six long-term survivors received ampicillin therapy. Overall mortality was 68%. The data suggest that the enterococcus may emerge as a blood-borne pathogen in immunodepressed, postoperative patients receiving antibiotics for other infections of enteric origin. Antibiotic therapy specifically directed against this organism (and surgical drainage, if necessary) may be indicated during polymicrobial sepsis of enteric or mixed origin. If the spectrum of antibiotics does not include enterococcus, this organism can cause "breakthrough" sepsis, as can many other opportunistic organisms.

Enterococcal Bacteremia Without Endocarditis

Seventy-four cases of enterococcal bacteremia without endocarditis were reviewed retrospectively for the years 1963 through 1977. Thirty-nine patients had hospital-acquired infection, 27 had serious underlying disease, and 18 had polymicrobial bacteremia. The organisms isolated from the primary source of infection were similar in patients with pure enterococcal or polymicrobial bacteremia. The most common source was the urinary tract, followed by the abdomen, infected burns, and soft-tissue infections other than burns. The overall mortality was 34%, with significantly higher mortality in immunocompromised patients, including those with infected burn wounds. Mortality also was higher in patients with hospital-acquired infection. Eleven of the 25 deaths were considered directly related to enterococcal septicemia.

Azidocillin treatment of enterococcal septicemia.

Two cases of enterococcal septicemia are reported which were successfully treated with azidocillin, a new penicillin derivative more effective in vitro against enterococci than penicillin G and even ampicillin. One cholecystectomized patient had septicemia but no signs of endocarditis. The other developed enterococcal septicemia after a bladder catheterization. Aortic valve engagement followed with valvular destruction and progressive insufficiency of the heart This was successfully treated surgically. Both patients are now in a good state of health. In both cases azidocillin levels in serum were well above the bactericidal concentrations for the enterococci involved. In vitro studies demonstrated synergistic action of streptomycin, but further laboratory and clinical studies are necessary to guide a clinical exploitation of this effect.

Antibiotics and Chemotherapeutic Agents in Clinical and Laboratory Practice

Intended as a practical guide for physicians, laboratory workers, and students, this book purports to bring together in comprehensive and usable form the present fund of knowledge in this highly complex field. While it has some utility to workers in the field, it unfortunately falls far short of its goals. The primary defect is that the author discusses too many complicated subjects in a superficial way. About 30 pages are devoted to the use of antibiotics in specific diseases. While the author emphasizes that only summaries are presented, the fact remains that the section resembles a cookbook as much as anything else. Some of the recipes are very bad indeed. For example, colistin plus penicillin is recommended for enterococcal septicemia or meningitis. The general recommendation for septicemia is two antibiotics, one to be given intravenously at triple dose. No further details are provided. For acute meningitis, intravenous hydrocortisone is recommended